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Zhou XS, Fang JC, Ma XL, Zhang Y, Wang F, Chen X, Wu QS, Cao PX, Liu HX. [Study on the inhibitory and pro-apoptotic effects of different concentrations of total tanshinone alone and in combination with tyrosine kinase inhibitors on human myeloid leukemia cell lines]. Zhonghua Yi Xue Za Zhi 2024; 104:1514-1520. [PMID: 38706059 DOI: 10.3760/cma.j.cn112137-20231013-00727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Objective: To explore the effect and investigate the molecular mechanism of different concentrations of total tanshinones alone and in combination with tyrosine kinase inhibitors (TKIs) on the proliferation inhibition and apoptosis of human myeloid leukemia cell lines. Methods: K562 and Kasumi-1 cell lines were purchased from the Shanghai Cell Bank of the Chinese Academy of Sciences, and the TKIs-resistant strain K562/T315I cell line was constructed in Molecular Medicine Research Center, Beijing Lu Daopei Institute of Hematology. Logarithmic growth phase cells were taken and divided into intervention groups with total tanshinone of 0, 2.19, 4.38, 8.75, 17.50 and 35.00 μg/ml intervention groups, which were inoculated in 96-well plates at a density of 1×104 cells/well and exposed to the drug for 24 h, and a control group treated with dimethyl sulfoxide was also set up simultaneously. All experiments were repeated independently 3-5 times. The proliferative activity of the cells was assessed using the CCK-8 assay, the apoptotic rates were measured by flow cytometry, and the expression levels of apoptosis-regulating proteins Bcl-2 and Bax were analyzed by Western blotting. The cell lines treated and untreated with total tanshinone were subjected to transcriptome sequencing and gene set enrichment analysis to identify differentially expressed genes. Results: The half-inhibitory concentration (IC50) values of 8.75 μg/ml total tanshinone at 24 h for K562, K562/T315I and Kasumi-1 cells were (4.11±0.02), (4.95±0.04) and (3.98±0.01) μg/ml, respectively. When combined with 0.25 μmol/L imatinib, 8.75 μg/ml total tanshinone could enhance the induction of apoptosis effects on K562 and K562/T315I cell lines. After being treated with 4.38, 8.75, and 17.50 μg/ml of total tanshinone for 24 h, compared with the control group, total tanshinone upregulated the expression level of Bax protein, downregulated the expression level of Bcl-2 protein, and decreased the Bcl-2/Bax ratio (all P<0.05). Total tanshinone inhibited the proliferation-related signaling pathway and DNA damage repair pathway of myeloid leukemia cell lines, and activated the signaling pathway that induces apoptosis in leukemia cells. Conclusion: Different concentrations of total tanshinoneinhibites proliferation and promote apoptosis in K562, Kasumi-1 and TKIs-resistant K562/T315I cell lines, and further enhance the anti-leukemic effect when combined with TKIs.
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Affiliation(s)
- X S Zhou
- Molecular Medicine Research Center, Beijing Lu Daopei Institute of Hematology,Beijing 100176, China
| | - J C Fang
- Division of Laboratory Medicine, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - X L Ma
- Division of Laboratory Medicine, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - Y Zhang
- Division of Laboratory Medicine, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - F Wang
- Division of Laboratory Medicine, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - X Chen
- Division of Laboratory Medicine, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - Q S Wu
- Division of Pathology & Laboratory Medicine, Beijing Lu Daopei Hospital, Beijing 100176, China
| | - P X Cao
- Division of Laboratory Medicine, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - H X Liu
- Division of Laboratory Medicine, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
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Gawron AJ, Horner B, Zurbuchen R, Boynton K, Fang JC. A comprehensive intervention to enhance inpatient colon preparation quality for colonoscopy. Minerva Gastroenterol (Torino) 2023; 69:351-358. [PMID: 33793164 DOI: 10.23736/s2724-5985.21.02766-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Adequate colon preparation is a critical component of high-quality colonoscopy especially for inpatients undergoing colonoscopy for acute indications. Inpatient colonoscopy has a high incidence of inadequate preparations. We report implementation of a multifaceted quality improvement intervention to improve inpatient colonoscopy preparations. METHODS Bowel preparation quality from inpatient colonoscopies performed for the 12 months prior to the comprehensive intervention were compared to colonoscopies performed for 12 months following the intervention. The intervention had multiple components including: 1) EMR-based colonoscopy preparation order set; 2) automated EMR alerts prompting nursing assessment of preparation progress; 3) standardized nursing charting processes for tracking preparation progress; and 4) standardized education for nursing staff and ordering providers on adequate colon preparation, assessment of colon preparation quality, and use of the above processes; and print and video patient education materials. RESULTS Two hundred thirty-eight inpatient colonoscopies were performed in the preintervention assessment period and 163 colonoscopies in the postintervention period. Median preintervention Boston Bowel Preparation Score (BBPS) was 6 and 26% of patients had inadequate colon preparation. Median postintervention BBPS was 8 with 16% inadequate colon preparation (P=0.016). The postintervention group had less ASA class I patients and used a lower dose of fentanyl than the preintervention group. There were no other significant differences between the pre- and postintervention groups. CONCLUSIONS Implementation of a comprehensive colon preparation quality intervention resulted in significantly improved inpatient colon preparation quality and decreased frequency of inadequate preparations. The intervention consisting of an EMR-based order-set, nursing alerts and charting process, and patient education materials is continually being refined.
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Affiliation(s)
- Andrew J Gawron
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Brian Horner
- Cheyenne Regional Medical Center, Cheyenne, WY, USA
| | - Rudi Zurbuchen
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - John C Fang
- University of Utah School of Medicine, Salt Lake City, UT, USA -
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Toy G, Colletier K, Hale G, Valentine J, Gawron AJ, Sossenheimer M, Peterson K, Aparicio R, Fang JC. Incidence of retained biopsy specimens after esophagogastroduodenoscopy and colonoscopy. Endosc Int Open 2023; 11:E653-E659. [PMID: 37614326 PMCID: PMC10442972 DOI: 10.1055/a-2098-2470] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 05/03/2023] [Indexed: 08/25/2023] Open
Abstract
Background and study aims In gastrointestinal endoscopy, biopsies must transit through the accessory channel and cap, presenting an opportunity for loss of tissue. We sought to determine the incidence of specimen retention in the accessory channel or cap and identify procedure characteristics associated with specimen retention. Patients and methods After completion of standard endoscopic procedures in which biopsies were obtained, the biopsy cap and accessory channel were inspected, brushed, and irrigated for any retained biopsy specimens according to a standard protocol. For controls, the same protocol was applied to procedures in which biopsies were not obtained. Specimen bottles from the recovery protocol were sent for pathological examination regardless of whether any visible tissue was present. Results A total of 216 outpatient procedures were included: 55 esophagogastroduodenoscopies (EGDs) and 50 colonoscopies in which biopsies were obtained and 56 EGDs and 55 colonoscopies in the control group. Retained specimens were found in either the cap or channel in 50 of 105 (48%). In 20 of 105 (19%), retained specimens were found just in the cap, in six of 105 (5.7%), retained specimens were found just in the channel, while in 24 of 105 (23%), retained specimens were found in both the cap and channel. Retained specimens were more likely to be found in EGDs compared to colonoscopies (58% vs. 36%, P = 0.031). No retained specimens were found in the control group. Conclusions Retained specimens are startingly common in standard gastrointestinal endoscopic procedures and could potentially change diagnoses and management. Quality improvement measures should be instituted to monitor prevalence of retained biopsies and methods to prevent them should be developed.
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Affiliation(s)
- Gregory Toy
- Gastroenterology, University of Utah, Salt Lake City, United States
| | - Keegan Colletier
- Gastroenterology, University of Utah, Salt Lake City, United States
| | - Gillian Hale
- Gastroenterology, University of Utah, Salt Lake City, United States
| | - John Valentine
- Gastroenterology, University of Utah, Salt Lake City, United States
| | | | | | - Kathryn Peterson
- Gastroenterology, University of Utah, Salt Lake City, United States
| | - Rodrigo Aparicio
- Gastroenterology, University of Utah, Salt Lake City, United States
| | - John C Fang
- Gastroenterology, University of Utah, Salt Lake City, United States
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Parbhu SK, Shah SC, Sossenheimer MJ, Fang JC, Peterson KA, Gawron AJ. Index diagnoses of gastric intestinal metaplasia in the United States: patient characteristics, endoscopic findings, and clinical practice patterns at a large tertiary care center. Therap Adv Gastroenterol 2022; 15:17562848221117640. [PMID: 36082176 PMCID: PMC9445457 DOI: 10.1177/17562848221117640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/18/2022] [Indexed: 02/04/2023] Open
Abstract
Background Gastric intestinal metaplasia (GIM) is a premalignant gastric mucosal change that is often incidentally detected during esophagogastroduodenoscopy (EGD). Despite the established higher risk of gastric cancer associated with GIM, the incidence, prevalence, and outcomes data for GIM are limited in the United States (US), and practice patterns are highly variable. Objectives Our primary objectives were to accurately identify incident histology-confirmed GIM cases and determine patient characteristics, endoscopy findings, Helicobacter pylori (HP) detection, and eradication treatment outcomes, as well as surveillance and follow-up recommendations. Design We conducted a retrospective cohort study using administrative data. Methods We first developed and validated a rule-based natural language processing tool to identify the patients with GIM on gastrointestinal pathology reports between 2011 and 2016. We then performed a manual chart review of all EGD procedures and associated pathology notes to confirm cases and obtain clinically relevant data. Results In all, 414 patients with an index diagnosis of GIM were confirmed (prevalence = 2.5% of patients undergoing any EGD). A majority (52.4%) of patients were non-Hispanic white. The most common indication for EGD was abdominal pain (46.9%). A majority (55%) did not receive specific follow-up recommendations or were asked to see their primary care provider. HP testing was documented in 86% of patients, and detected in 94 patients (prevalence = 26.4%). Treatment was documented in 94.7% of cases, and eradication confirmed in only 34.8% of these cases. Conclusion A large group of US patients with an index diagnosis of GIM was accurately identified. There was wide variability in clinical practice patterns including biopsy practice, HP treatment and eradication confirmation testing, and surveillance recommendations. This work demonstrates that there is a major unmet need for quality improvement efforts to standardize care for patients with GIM, a premalignant condition, and inform future prospective studies in a US population.
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Affiliation(s)
- Sheeva K. Parbhu
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shailja C. Shah
- Division of Gastroenterology, University of California San Diego, San Diego, CA, USA Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Michael J. Sossenheimer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - John C. Fang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kathryn A. Peterson
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
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Peterson K, Clayton F, Qeadan F, Gorman D, Robson J, Allen-Brady K, Fang JC. Esophageal Eosinophilia Is Common Among Relatives of Eosinophilic Esophagitis Patients. Clin Gastroenterol Hepatol 2022; 20:e957-e963. [PMID: 33221551 DOI: 10.1016/j.cgh.2020.11.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/29/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Familial clustering of eosinophilic esophagitis (EoE) has been described, and we report on the biopsy-assessed prevalence of esophageal eosinophilia (EE) in first-degree family members. The aim was to determine the prevalence of EE in first-degree adult relatives (FDRs) of EoE patients. METHODS Index EoE patients diagnosed by EE (>15 eosinophils per high-power field) and proton pump inhibitor nonresponsiveness were identified and family trees were constructed. Adult FDRs were invited to undergo upper endoscopy with esophageal biopsies and to complete reflux, dysphagia, and allergy/atopy questionnaires. Questionnaire information was gathered only for those who responded as per institutional review board purview. Records from other children and adult FDRs with prior EoE diagnoses also were obtained when permission was obtained. Simple and multivariable logistic regression models were used to evaluate the unadjusted and odds ratios of EoE for demographic and clinical variables. RESULTS A total of 239 FDRs from 37 index EoE patients were identified. Seventy-one of 239 adult (age, >18 y) FDRs completed endoscopy and questionnaires and 18 of 71 FDRs had EE. An additional 17 FDRs were confirmed to have EE after external medical record retrieval, resulting in a total of 35 of 239 (14.6%) FDRs with EE. Significantly more male FDRs had EE compared with female FDRs (P = .027). Proton pump inhibitors, dysphagia, gastroesophageal reflux disease, asthma, and reflux symptoms predicted EE in FDRs. FDRs who had EE reported hay fever, allergic eye symptoms, and food allergy more frequently than those without EE (P = .03, P = .001, and P = .02, respectively). Specifically, younger age, higher serum eosinophils, being male, and having food allergies all were associated with higher odds of EoE (P = .0211, P = .0031, P = .0362, and P = .0089, respectively). CONCLUSIONS The prevalence of esophageal eosinophilia is extremely high and male-predominant in first-degree relatives of EoE patients. Symptoms of hay fever, allergic eye symptoms, and food allergy were predictors of EE in FDRs. Dysphagia did not predict esophageal eosinophilia. Family members of EoE patients are at risk for EE, particularly those who have atopic symptoms.
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Affiliation(s)
| | | | - Fares Qeadan
- Department of Family and Preventative Medicine, Salt Lake City, Utah
| | - Darcie Gorman
- Department of Gastroenterology, Intermountain Medical Group, Salt Lake City, Utah
| | - Jacob Robson
- Department of Pediatric Gastroenterology/Nutrition, Primary Children's Hospital, Salt Lake City, Utah
| | | | - John C Fang
- Department of Gastroenterology, Salt Lake City, Utah.
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Zhang JS, Xu HY, Fang JC, Yin BZ, Wang BB, Pang Z, Xia GJ. Integrated microRNA-mRNA analysis reveals the roles of microRNAs in the muscle fat metabolism of Yanbian cattle. Anim Genet 2021; 52:598-607. [PMID: 34350996 DOI: 10.1111/age.13126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 12/16/2022]
Abstract
Fat deposition is an important economic trait in farm animals. However, it is difficult to genetically improve intramuscular fat deposition via trait-based cattle breeding. The main objectives of this study were to analyze the factors about beef flavor, and to detect functional microRNA (miRNA, miR) associated with intramuscular fat deposition in Yanbian cattle. Longissimus dorsi samples from six steers were separated into high- and low-fat groups (n = 3 each) based on the marbling score, and transcriptomic analysis was performed using miRNA sequencing. A total of 33 miRNAs and 38 genes were found to be differentially expressed in the high- and low-fat groups. Quantitative real-time polymerase chain reaction was performed to validate the sequencing results. Integrated miRNA-mRNA analysis revealed that miRNA-associated target genes were primarily associated with skeletal muscle development. However, some of the miRNAs (miR-424 etc.) and genes (ATF3 etc.) were also associated with fat metabolism. A targeted relationship between miR-22-3p and the WFIKKN2 gene and its involvement in adipocyte differentiation were confirmed experimentally. The study findings may provide potential candidate molecular targets for the selection of cattle with improved meat quality.
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Affiliation(s)
- J S Zhang
- College of Agriculture, Yanbian University, Yanji, 133002, China
| | - H Y Xu
- College of Agriculture, Yanbian University, Yanji, 133002, China
| | - J C Fang
- Faculty of Agriculture and Life Science, Hirosaki University, Hirosaki, Japan
| | - B Z Yin
- College of Agriculture, Yanbian University, Yanji, 133002, China
| | - B B Wang
- College of Agriculture, Yanbian University, Yanji, 133002, China
| | - Z Pang
- College of Agriculture, Yanbian University, Yanji, 133002, China
| | - G J Xia
- College of Agriculture, Yanbian University, Yanji, 133002, China.,Engineering Research Center of North-East Cold Region Beef Cattle Science & Technology Innovation, Ministry of Education, Yanbian University, Yanji, 133002, China
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Ma CM, Wu QS, Yu TT, Wei SP, Wang F, Fang JC, Nie DJ, Yuan LL, Zhang Y, Chen X, Liu M, Zhou XS, Zhou J, Liu HX. [ABO gene subtypes and gene expression analysis in three cases of hematological malignancies patients]. Zhonghua Yi Xue Za Zhi 2020; 100:3443-3447. [PMID: 33238676 DOI: 10.3760/cma.j.cn112137-20200618-01880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To explore the application and discovery of genotyping, gene sequencing, and gene expression analysis in the determination of ABO blood group subtypes and antigen expression abnormalities in hematological malignancies patients. Methods: From June 2019 to May 2020, three clinical cases were found with forward and reverse ABO typing discrepancy or atypical serologic agglutination pattern in the laboratory and blood transfusion department of Hebei Yanda Ludaopei Hospital were selected. Sequence-specific primer PCR (PCR-SSP) and Sanger sequencing of ABO gene coding regions were performed to determine the ABO genotypes, and whole transcriptome sequencing was used to analyze ABO and FUT1 gene expression levels. Results: A 12-year-old female acute lymphoblastic leukemia patient was determined as O.01.02 and BA.04 sub-genotype, corresponding to the serological B(A) subtype, and her ABO gene expression was normal (354.80). A 41-year-old female acute myeloid leukemia patient was determined as A1.02 and B.01 genotype, corresponding to the serological A(1)B phenotype, and her ABO gene expression was significantly reduced (45.70). A 42-year-old male with myelodysplastic syndrome and myelofibrosis was determined as A1.02 and A2.05 sub-genotype, corresponding to the serological A(1) and A(2) phenotype, respectively, and his ABO expression was negative. FUT1 expression was in the normal range in all three cases. The clinical blood product infusion strategy was formulated according to the genotype and the corresponding immunological subtype, and no significant transfusion-related adverse reactions occurred. Conclusion: Blood group sub-genotypes or aberrant gene expression can lead to ambiguities in serological blood group determination in hematological malignancies patients. ABO genotyping and gene expression analysis can help in this scenario and escort blood product infusion safety.
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Affiliation(s)
- C M Ma
- Langfang Central Blood Station, Langfang 065000
| | - Q S Wu
- Division of Pathology and Laboratory Medicine, Beijing Ludaopei Hospital, Beijing 100176, China
| | - T T Yu
- Division of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - S P Wei
- Blood Transfusion Department, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - F Wang
- Division of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - J C Fang
- Division of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - D J Nie
- Division of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - L L Yuan
- Division of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - Y Zhang
- Division of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - X Chen
- Division of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - M Liu
- Division of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - X S Zhou
- Division of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - J Zhou
- Blood Transfusion Department, Hebei Yanda Ludaopei Hospital, Langfang 065201, China
| | - H X Liu
- Beijing Ludaopei Institute of Hematology, Beijing 100176, China
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Fogarty M, Orr JA, Sakata D, Brewer L, Johnson K, Fang JC, Kuck K. A comparison of ventilation with a non-invasive ventilator versus standard O 2 with a nasal cannula for colonoscopy with moderate sedation using propofol. J Clin Monit Comput 2019; 34:1215-1221. [PMID: 31760586 DOI: 10.1007/s10877-019-00426-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/17/2019] [Indexed: 12/27/2022]
Abstract
The aim of this study was to test the effects of CPAP on moderately sedated patients undergoing colonoscopy. Our hypothesis was that CPAP can reduce the incidence and duration of obstructive apnea and hemoglobin oxygen desaturation in patients undergoing procedural sedation for colonoscopy. Two groups of consenting adult patients scheduled to undergo routine colonoscopy procedures and sedated with propofol and fentanyl were monitored in this study: control and intervention. Patients in the intervention group were connected via a facemask to a ventilator that delivered supplemental oxygen (100%) through a standard air-cushion mask. The mask had a built-in leak to facilitate CO2 clearance during CPAP. Patients in the control group received 2-10 L/min of oxygen via nasal cannula or non-rebreather mask. Subjects in the control group were collected in a prior study and used as historical controls. The primary outcome measures were the number of apneic events and the cumulative duration of apneic events. An apneic event was defined as a period longer than 10 s without respiration. The secondary outcome was the area under the curve (AUC) for the arterial oxygen saturation less than 90% versus time during sedative and analgesic administration (time (s) below threshold multiplied by percent below threshold). A desaturation event was defined as a period of time during which arterial oxygen saturation was less than 90%. 29 patients were enrolled in the intervention group and 156 patients were previously enrolled in the control group as part of an earlier study. The median number of apneic events in the control group was 7 compared to 0 in the intervention group. The intervention group experienced apnea less than 1% of the total procedure time compared to 17% in the control group (p < 0.001). There were no desaturation events observed in the 29 patients in the intervention group. In contrast, 27 out of 156 patients in the control group experienced a desaturation event. Average AUC of patients in the control group was 70%-s (time (s) * oxygen saturation below < 90%) (95% CI 32.34-108.60%) whereas the average AUC in intervention group patients was 0%-s (% time (s) * oxygen saturation < 90%) (95% CI 0-0%), p = 0.01. This preliminary study found that CPAP via a tight-fitting mask may be an effective tool to reduce the incidence and duration of obstructive apneic events as well as hemoglobin oxygen desaturation during lower endoscopy procedures that use propofol and fentanyl for sedation.Clinical Trial Registration ClinicalTrials.gov ID: NCT02623270. https://clinicaltrials.gov/ct2/show/NCT02623270 .
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Affiliation(s)
- Mike Fogarty
- Department of Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT, USA.
| | - Joseph A Orr
- Department of Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Derek Sakata
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Lara Brewer
- Department of Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Ken Johnson
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - John C Fang
- Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Kai Kuck
- Department of Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT, USA
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Taleb I, Yin MY, Koliopoulou AG, Taleb M, Dranow E, Kemeyou L, McKellar SH, Caine W, Wever-Pinzon O, Alharethi R, Kfoury AG, Fang JC, Stehlik J, Selzman CH, Drakos SG. P5419Cardiac reverse remodeling and recovery in dilated cardiomyopathy medication-naive patients requiring durable left ventricular assist device support. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Occasionally new onset cardiomyopathy patients (pts) present late and with such advanced disease stage that they cannot tolerate heart failure (HF) drug therapy. We sought to investigate the cardiac recovery (CR) potential following a combination of left ventricular assist device (LVAD) and guideline-directed HF drug therapy in this medication-naive population.
Methods
Chronic advanced HF requiring durable continuous-flow LVAD were prospectively evaluated. Patients with acute HF (myocarditis etc.) or post LVAD follow up <3 months were excluded. The “meds-treated” group (n=203) comprised patients treated adequately with at least one neurohormonal blocking agent during their HF history (b-blocker, ACEI/ARB, Aldosterone antagonist) and “meds-naive” group (n=8) comprised patients who were never before treated adequately with any HF medication. Baseline and follow up clinical, hemodynamic, imaging and laboratory data were analyzed. LVAD patients were phenotyped as CR responders or non responders, based on published predefined criteria.
Results
Univariate analysis showed that “med-naive” patients were younger, more likely to be on intravenous vasoactive agents, temporary mechanical support and with lower INTERMACS profile before LVAD implantation. Interestingly, no differences were seen in HF symptoms duration or other comorbidities. Baseline and follow up hemodynamics were similar in both groups, besides higher right atrial pressure pre-LVAD in the “meds-naive” group (16 vs 11 mmHg; p=0.04). Baseline echocardiographic (including LV dilation) and biochemical parameters revealed no differences between the groups, besides lower LVEF and higher BNP in the “meds-naive” group (14 vs 19%; p=0.03 and 2352 vs 1270; p=0.03, respectively). CR rates were significantly higher on “meds-naive” versus “meds-failed” group (50.0 vs 13.8%; p=0.005). Despite higher cardiac recovery rates in the “meds-naive” group the time course and magnitude of the favorable functional and structural response was similar among the CR responders of each of the 2 groups.
Conclusion
Young patients with new onset dilated cardiomyopathy sometimes present late, with advanced disease stage, unable to tolerate HF medications and requiring durable LVAD support. This patient population appears to have a potential for CR up to 50% and this could be factored in decisions surrounding their long-term therapeutic options.
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Affiliation(s)
- I Taleb
- University of Utah, Salt Lake City, United States of America
| | - M Y Yin
- University of Utah, Salt Lake City, United States of America
| | - A G Koliopoulou
- University of Utah, Salt Lake City, United States of America
| | - M Taleb
- University of Utah, Salt Lake City, United States of America
| | - E Dranow
- University of Utah, Salt Lake City, United States of America
| | - L Kemeyou
- University of Utah, Salt Lake City, United States of America
| | - S H McKellar
- University of Utah, Salt Lake City, United States of America
| | - W Caine
- Intermountain Medical Center, Salt Lake City, United States of America
| | - O Wever-Pinzon
- University of Utah, Salt Lake City, United States of America
| | - R Alharethi
- Intermountain Medical Center, Salt Lake City, United States of America
| | - A G Kfoury
- Intermountain Medical Center, Salt Lake City, United States of America
| | - J C Fang
- University of Utah, Salt Lake City, United States of America
| | - J Stehlik
- University of Utah, Salt Lake City, United States of America
| | - C H Selzman
- University of Utah, Salt Lake City, United States of America
| | - S G Drakos
- University of Utah, Salt Lake City, United States of America
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10
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Taleb I, Horne BD, Yin MY, Nativi-Nicolau J, Wever-Pinzon O, McKellar SH, Caine W, Koliopoulou AG, Alharethi R, Kfoury AG, Gilbert EM, Fang JC, Stehlik J, Selzman CH, Drakos SG. P2628Predicting cardiac recovery before durable left ventricular assist device implantation in advanced heart failure patients. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Predicting cardiac recovery (CR) in advanced heart failure (HF) patients before left ventricular assist device (LVAD) implantation remains challenging. This study sought to investigate whether CR after LVAD unloading can be predicted by cardiac functional and structural parameters together with clinical characteristics.
Methods
From 2008 to 2016, consecutive advanced chronic HF patients (N=347) supported with durable continuous-flow LVADs were prospectively evaluated. Patients with acute HF etiologies or without adequate post-LVAD follow up (<3 months) were excluded. A great variety of clinical characteristics were evaluated in the remaining 285 subjects. LVAD patients were phenotyped while on support, as CR Responders or Non Responders, based on published predefined echocardiographic criteria. Multivariable logistic regression was used to form the model and the Utah Cardiac Recovery (UCAR) score was created from the regression beta coefficients of the final model.
Results
CR occurred in 13.7% of patients. Univariate analysis showed that responders were more likely to be young, female, non-ischemic cardiomyopathy, with shorter HF symptoms duration and no prior cardiac surgery. They had lower blood urea nitrogen and were more likely to be on temporary mechanical support before LVAD. The multivariable UCAR model (AUC=0.755; p<0.001) predicted CR using 3 clinical parameters – Figure.
Conclusion
Univariate and multivariable predictors of CR include both modifiable and non-modifiable patient characteristics that are known prior to LVAD implantation. The UCAR score can serve as a practical tool for targeted patient selection to implement protocols that facilitate CR in the advanced HF patient subpopulation that is most likely to respond.
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Affiliation(s)
- I Taleb
- University of Utah, Salt Lake City, United States of America
| | - B D Horne
- Intermountain Medical Center, Salt Lake City, United States of America
| | - M Y Yin
- University of Utah, Salt Lake City, United States of America
| | | | - O Wever-Pinzon
- University of Utah, Salt Lake City, United States of America
| | - S H McKellar
- University of Utah, Salt Lake City, United States of America
| | - W Caine
- Intermountain Medical Center, Salt Lake City, United States of America
| | - A G Koliopoulou
- University of Utah, Salt Lake City, United States of America
| | - R Alharethi
- Intermountain Medical Center, Salt Lake City, United States of America
| | - A G Kfoury
- Intermountain Medical Center, Salt Lake City, United States of America
| | - E M Gilbert
- University of Utah, Salt Lake City, United States of America
| | - J C Fang
- University of Utah, Salt Lake City, United States of America
| | - J Stehlik
- University of Utah, Salt Lake City, United States of America
| | - C H Selzman
- University of Utah, Salt Lake City, United States of America
| | - S G Drakos
- University of Utah, Salt Lake City, United States of America
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11
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Dixon R, Burton S, Taylor LJ, Richeson BL, Fang JC. Bezoar formation on percutaneous endoscopic gastrojejunostomy tube causing gastric outlet obstruction and small-intestinal intussusception. VideoGIE 2019; 4:416-417. [PMID: 31517166 PMCID: PMC6731367 DOI: 10.1016/j.vgie.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Robert Dixon
- Division of Gastroenterology, Hepatology, and Nutrition, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sarah Burton
- Division of Gastroenterology, Hepatology, and Nutrition, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Linda Jo Taylor
- Division of Gastroenterology, Hepatology, and Nutrition, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin L Richeson
- Division of Gastroenterology, Hepatology, and Nutrition, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John C Fang
- Division of Gastroenterology, Hepatology, and Nutrition, University of Utah School of Medicine, Salt Lake City, Utah, USA
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12
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Dixon R, Adler DG, Sossenheimer M, Taylor LJ, Fang JC. Corneal injury after routine gastrointestinal endoscopy with moderate sedation. Ann Gastroenterol 2019; 32:419-421. [PMID: 31263366 PMCID: PMC6595936 DOI: 10.20524/aog.2019.0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 02/04/2019] [Indexed: 11/15/2022] Open
Abstract
We report a case series of 4 patients who underwent routine gastrointestinal endoscopy under moderate sedation and developed corneal injuries. Although corneal abrasion has been reported as the most common ocular complication during non-ocular surgery under general anesthesia, the risk for corneal abrasion during routine endoscopic procedures using moderate sedation has not been previously reported. Symptoms reported included ocular burning, scratchy sensation, redness, and pain reported post-procedure. Endoscopists and staff should be alert to the occurrence of this potentially serious complication, as this is paramount for its prevention, diagnosis, and management. Treatment of corneal abrasion includes referral to ophthalmology for close monitoring, pain management, pressure patch, and antimicrobial prophylaxis.
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Affiliation(s)
- Robert Dixon
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah School of Medicine, USA
| | - Douglas G Adler
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah School of Medicine, USA
| | - Michael Sossenheimer
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah School of Medicine, USA
| | - Linda Jo Taylor
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah School of Medicine, USA
| | - John C Fang
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah School of Medicine, USA
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13
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McVay TR, Garrett G C, Celena B P, Klaus B, Fang JC, Chapman WW, Samore MH, Gawron AJ. Natural Language Processing Accurately Identifies Dysphagia Indications for Esophagogastroduodenoscopy Procedures in a Large US Integrated Healthcare System: Implications for Classifying Overuse and Quality Measurement. AMIA Jt Summits Transl Sci Proc 2019; 2019:665-671. [PMID: 31259022 PMCID: PMC6568132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Recent evidence suggests almost half of repeat esophagogastroduodenoscopy procedures (EGDs) are overused; this prior research relied on administrative data that are often inaccurate. Our primary objective was to determine and compare the accuracy of natural language processing and administrative data to manual chart review to identify dysphagia indications for EGD procedures within the national VA healthcare system. From 396,856 EGD notes identified from 2008-2014, we classified 119,920 as "index" procedures in 2010-2012. We compared the performance of our NLP to ICD codes to correctly identify dysphagia indications in the index EGD procedures and in repeat EGD procedures. We used linked pathology data to describe esophageal biopsies performed during these EGDs. NLP performed significantly better and identified significantly more index and repeat EGD procedures with dysphagia indications than ICD codes, which has critical implications for determining appropriateness of EGD procedures.
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Affiliation(s)
- Tyler R McVay
- University of Utah, Salt Lake City, UT
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT
| | - Cole Garrett G
- University of Utah, Salt Lake City, UT
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT
| | - Peters Celena B
- University of Utah, Salt Lake City, UT
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT
| | - Bielefeldt Klaus
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT
| | - John C Fang
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT
| | | | - Matt H Samore
- University of Utah, Salt Lake City, UT
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT
| | - Andrew J Gawron
- University of Utah, Salt Lake City, UT
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT
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14
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Sullivan S, Swain J, Woodman G, Edmundowicz S, Hassanein T, Shayani V, Fang JC, Noar M, Eid G, English WJ, Tariq N, Larsen M, Jonnalagadda SS, Riff DS, Ponce J, Early D, Volckmann E, Ibele AR, Spann MD, Krishnan K, Bucobo JC, Pryor A. Randomized sham-controlled trial of the 6-month swallowable gas-filled intragastric balloon system for weight loss. Surg Obes Relat Dis 2018; 14:1876-1889. [PMID: 30545596 DOI: 10.1016/j.soard.2018.09.486] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/14/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Obesity is a significant health problem and additional therapies are needed to improve obesity treatment. OBJECTIVE Determine the efficacy and safety of a 6-month swallowable gas-filled intragastric balloon system for weight loss. SETTING Fifteen academic and private practice centers in the United States. METHODS This was a double-blind, randomized sham-controlled trial of the swallowable gas-filled intragastric balloon system plus lifestyle therapy compared with lifestyle therapy alone for weight loss at 6 months in participants aged 22 to 60 years with body mass index 30 to 40 kg/m2, across 15 sites in the United States. The following endpoints were included: difference in percent total weight loss in treatment group versus control group was >2.1%, and a responder rate of >35% in the treatment group. RESULTS Three hundred eighty-seven patients swallowed at least 1 capsule. Of participants, 93.3% completed all 24 weeks of blinded study testing. Nonserious adverse events occurred in 91.1% of patients, but only .4% were severe. One bleeding ulcer and 1 balloon deflation occurred. In analysis of patients who completed treatment, the treatment and control groups achieved 7.1 ± 5.0% and 3.6 ± 5.1% total weight loss, respectively, and a mean difference of 3.5% (P = .0085). Total weight loss in treatment and control groups were 7.1 ± 5.3 and 3.6 ± 5.1 kg (P < .0001), and body mass index change in the treatment and control groups were 2.5 ± 1.8 and 1.3 ± 1.8 kg/m2 (P < .0001), respectively. The responder rate in the treatment group was 66.7% (P < .0001). Weight loss maintenance in the treatment group was 88.5% at 48 weeks. CONCLUSIONS Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.
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Affiliation(s)
- Shelby Sullivan
- Washington University School of Medicine, St. Louis, Missouri; University of Colorado School of Medicine, Aurora, Colorado.
| | - James Swain
- HonorHealth Research Institute, Scottsdale, Arizona
| | | | - Steven Edmundowicz
- Washington University School of Medicine, St. Louis, Missouri; University of Colorado School of Medicine, Aurora, Colorado
| | | | - Vafa Shayani
- Bariatric Institute of Greater Chicago, Bolingbrook, Illinois
| | - John C Fang
- University of Utah Hospital, Salt Lake City, Utah
| | - Mark Noar
- Endoscopy Microsurgery Associates, Townson, Maryland
| | - George Eid
- Alleghany Singer Research at West Penn, Pittsburgh, Pennsylvania
| | | | - Nabil Tariq
- Houston Methodist Research Institute, Houston, Texas
| | | | | | | | - Jaime Ponce
- Chattanooga Bariatrics, Chattanooga, Tennessee
| | - Dayna Early
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Anna R Ibele
- University of Utah Hospital, Salt Lake City, Utah
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15
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Beldhuis IE, Myhre PL, Claggett B, Damman K, Fang JC, Lewis EF, O'Meara E, Pitt B, Shah SJ, Voors AA, Pfeffer MA, Solomon SD, Desai AS. P6508Balance of risk and benefit of spironolactone according to renal function in heart failure patients with preserved ejection fraction. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- I E Beldhuis
- Brigham and Women's Hospital, Cardiovascular Division, Boston, United States of America
| | - P L Myhre
- Brigham and Women's Hospital, Cardiovascular Division, Boston, United States of America
| | - B Claggett
- Brigham and Women's Hospital, Cardiovascular Division, Boston, United States of America
| | - K Damman
- University Medical Center Groningen, Department of Cardiology, Groningen, Netherlands
| | - J C Fang
- University of Utah School of Medicine, Salt Lake City, United States of America
| | - E F Lewis
- Brigham and Women's Hospital, Cardiovascular Division, Boston, United States of America
| | - E O'Meara
- Montreal Heart Institute, Montreal, Canada
| | - B Pitt
- University of Michigan School of Medicine, Ann Arbor, United States of America
| | - S J Shah
- Northwestern University Medical Center, Division of Cardiology, Chicago, United States of America
| | - A A Voors
- University Medical Center Groningen, Department of Cardiology, Groningen, Netherlands
| | - M A Pfeffer
- Brigham and Women's Hospital, Cardiovascular Division, Boston, United States of America
| | - S D Solomon
- Brigham and Women's Hospital, Cardiovascular Division, Boston, United States of America
| | - A S Desai
- Brigham and Women's Hospital, Cardiovascular Division, Boston, United States of America
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16
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Fang JC, Faerber G, Samadder J. Digital rectal examination for prostate cancer screening performed with colonoscopy for colon cancer screening: 2 for the price of 1. Gastrointest Endosc 2017; 86:1147-1150. [PMID: 28739176 DOI: 10.1016/j.gie.2017.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/17/2017] [Indexed: 12/11/2022]
Affiliation(s)
- John C Fang
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah Health, Salt Lake City, Utah, USA
| | - Gary Faerber
- Division of Urology, University of Utah Health, Salt Lake City, Utah, USA
| | - Jewel Samadder
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah Health, Salt Lake City, Utah, USA
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17
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Fang JC, DiSario JA. Strategies in Managing Chronic Pancreatitis–Placement of Direct Percutaneous Endoscopic Jejunostomy Feeding Tubes. Nutr Clin Pract 2016; 19:50-5. [PMID: 16215096 DOI: 10.1177/011542650401900150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Patients with chronic pancreatitis (CP) often have maldigestion and malnutrition. Nutrition support during acute and CP traditionally has been provided by parenteral nutrition. In acute pancreatitis, jejunal feeding may accelerate resolution of the inflammatory process, protect against infection, and improve outcomes at a reduced cost when compared with parenteral nutrition. Jejunal feeding may also be beneficial for patients with CP. Prolonged jejunal access may be achieved via a direct percutaneous endoscopic jejunostomy (DPEJ). This article will review the rationale and evidence for jejunal feeding, indications and contraindictions for DPEJ placement, and the technique and outcomes of DPEJ in patients with CP.
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Affiliation(s)
- John C Fang
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah Health Sciences Center, 30 North 1900 East, Room 4R118, Salt Lake City, Utah 84132-2410, USA.
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18
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Murphy CJ, Adler DG, Cox K, Sommers DN, Fang JC. Insufflation with carbon dioxide reduces pneumoperitoneum after percutaneous endoscopic gastrostomy (PEG): a randomized controlled trial. Endosc Int Open 2016; 4:E292-5. [PMID: 27004246 PMCID: PMC4798931 DOI: 10.1055/s-0042-100192] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 12/16/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Pneumoperitoneum following PEG placement has been reported in up to 60 % of cases, and while usually benign and self-limited, it can lead to evaluation for suspected perforation. This study was designed to determine whether using CO2 compared to ambient air for insufflation during PEG reduces post-procedure pneumoperitoneum. PATIENTS AND METHODS Prospective, double-blind, randomized trial of 35 consecutive patients undergoing PEG at a single academic medical center. Patients were randomized to insufflation with CO2 or ambient air. The primary outcome was pneumoperitoneum determined by left-lateral decubitus abdominal x-rays 30 minutes after PEG placement. Secondary endpoints included abdominal distention, pain, and bloating. RESULTS PEG was successfully placed in 17 patients using CO2 and 18 patients using ambient air. Three patients in each arm were unable or declined to have x-rays completed and were excluded. Pneumoperitoneum was identified in 2/14 (14.3 %) using CO2 and 8/15 (53.3 %) using ambient air (P = 0.05). There was no significant difference in abdominal distention, visual analog scale (VAS) scores for pain or bloating between CO2 and ambient air. CONCLUSION Utilizing CO2 significantly reduces the frequency of post-procedural pneumoperitoneum compared to use of ambient air during PEG placement, with no difference in waist circumference, pain or bloating between CO2 and ambient air. CO2 appears to be safe and effective for use and may be the insufflation agent of choice during PEG.
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Affiliation(s)
- Christopher J. Murphy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Douglas G. Adler
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Kristen Cox
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Daniel N. Sommers
- Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - John C. Fang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States,Corresponding author John C. Fang, MD Division of Gastroenterology, Hepatology, and NutritionDepartment of Internal MedicineThe University of Utah School of Medicine30 N 1900 ERoom 4R118Salt Lake CityUtah 84132
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19
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Murphy CJ, Jewel Samadder N, Cox K, Iqbal R, So B, Croxford D, Fang JC. Outcomes of Next-Day Versus Non-next-Day Colonoscopy After an Initial Inadequate Bowel Preparation. Dig Dis Sci 2016; 61:46-52. [PMID: 26289257 DOI: 10.1007/s10620-015-3833-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/29/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Inadequate bowel preparation is the most common cause of failed colonoscopy, and repeat failure occurs in more than 20 % of follow-up attempts. Limited data suggest that next-day follow-up may reduce the risk for repeat inadequate preparation. OBJECTIVE Evaluate differences in prep quality with next-day follow-up after initial inadequate preparation. DESIGN Retrospective study. SETTING Academic center. PATIENTS Outpatient screening and surveillance colonoscopies between 7/2002 and 6/2007. INTERVENTION Comparison of next-day versus any other day ("non-next-day") repeat colonoscopy outcomes. MAIN OUTCOME MEASUREMENTS Aronchick scale, polyp and adenoma detection rates. RESULTS Of 20,798 initial colonoscopies, 857 (4.1 %) had inadequate preparation. 460 (54 %) were lost to follow-up. One hundred and fourteen (13 %) had next-day and 283 (33 %) had non-next-day colonoscopy with mean follow-up of 8.8 months. On follow-up examination, 29.8 % of next-day and 23.3 % of non-next-day colonoscopies had inadequate bowel preparation (p = 0.48). The adenoma detection rate for the next-day group improved from 3.5 to 38.6 % on follow-up, compared to 20.5 and 36.8 % in the non-next-day group. There was no significant difference between groups in detection of total adenoma (p = 0.73) or advanced adenomas (p = 0.20) on follow-up examinations. LIMITATIONS Retrospective design, differences in baseline colonoscopy characteristics. CONCLUSION The results confirm the need for repeat examination after a colonoscopy with inadequate bowel prep, as there was substantial increase in adenoma detection on follow-up. There were no differences in outcomes between next-day versus non-next-day colonoscopy. These data support repeating after inadequate colonoscopy within 1 year as convenient for patient and physician.
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Affiliation(s)
| | - N Jewel Samadder
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Kristen Cox
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Ronak Iqbal
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Brian So
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Daniel Croxford
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - John C Fang
- University of Utah Health Sciences Center, Salt Lake City, UT, USA.
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20
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Affiliation(s)
- Frederic Clayton
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah
| | - John C Fang
- Gastroenterology Division, University of Utah School of Medicine, Salt Lake City, Utah
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
| | - Kathryn A Peterson
- Gastroenterology Division, University of Utah School of Medicine, Salt Lake City, Utah
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21
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Clayton F, Fang JC, Gleich GJ, Lucendo AJ, Olalla JM, Vinson LA, Lowichik A, Chen X, Emerson L, Cox K, O'Gorman MA, Peterson KA. Eosinophilic esophagitis in adults is associated with IgG4 and not mediated by IgE. Gastroenterology 2014; 147:602-9. [PMID: 24907494 DOI: 10.1053/j.gastro.2014.05.036] [Citation(s) in RCA: 308] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 05/06/2014] [Accepted: 05/28/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis is usually triggered by foods, by unclear mechanisms. We evaluated the roles of IgE and IgG4 in the development of eosinophilic esophagitis. METHODS We performed a prospective, randomized, double-blind, placebo-controlled trial of adults with eosinophilic esophagitis given an antibody against IgE (omalizumab, n = 16) or placebo (n = 14) every 2-4 weeks for 16 weeks, based on weight and serum level of IgE. Endoscopy was performed, esophageal biopsy specimens were collected, and symptoms were assessed at baseline and at 16 weeks. Maximum numbers of eosinophils/high-power field were determined. Homogenates of esophageal biopsy specimens from 11 subjects with eosinophilic esophagitis and 8 without (controls) were assessed for IgM, IgA, and IgG subclasses. In a retrospective analysis, we performed immunofluorescence analysis of IgG4 in fixed esophageal tissues from 2 patients with eosinophilic esophagitis who underwent esophagectomy and 47 consecutive autopsies (controls). We also performed immunofluorescence analysis of IgG4 in esophageal mucosal biopsy specimens from 24 subjects with eosinophilic esophagitis and 9 without (controls). Finally, sera were collected from 15 subjects with eosinophilic esophagitis and from 41 without (controls), and assayed for total and food-reactive IgG4. RESULTS Omalizumab did not alter symptoms of eosinophilic esophagitis or eosinophil counts in biopsy samples compared with placebo. Homogenates of esophageal tissues from patients with eosinophilic esophagitis had a 45-fold increase in IgG4 compared with controls (P < 3 × 10(-5)), but no significant increases in other IgG subclasses, IgM, or IgA. Sparse stromal deposits resembling immune complexes were found in 2 of 5 eosinophilic esophagitis biopsy specimens based on ultrastructural analysis. Esophagectomy samples from 2 patients with eosinophilic esophagitis contained 180 and 300 IgG4 plasma cells/maximal high-power field, mainly in the deep lamina propria; these levels were greater than in tissues from controls. Fibrosis essentially was exclusive to the lamina propria. Granular extracellular IgG4 was detected in biopsy specimens from 21 of 24 patients with eosinophilic esophagitis, but in none of the specimens from 9 controls (P = 6 × 10(-6)). The total serum level of IgG4 increased only slightly in patients with eosinophilic esophagitis, compared with controls. Subjects with eosinophilic esophagitis had increased serum levels of IgG4 that reacted with milk, wheat, egg, and nuts-the 4 foods that most commonly trigger this condition (P ≤ 3 × 10(-4) for each food). CONCLUSIONS In a prospective trial, omalizumab did not reduce symptoms of eosinophilic esophagitis or tissue eosinophil counts compared with placebo. This finding, along with observed granular deposits of IgG4, abundant IgG4-containing plasma cells, and serum levels of IgG4 reactive to specific foods, indicate that, in adults, eosinophilic esophagitis is IgG4-associated, and not an IgE-induced allergy. ClinicalTrials.gov number: NCT 00123630.
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Affiliation(s)
- Frederic Clayton
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah.
| | - John C Fang
- Gastroenterology Division, University of Utah School of Medicine, Salt Lake City, Utah
| | - Gerald J Gleich
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah; Department of Dermatology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
| | - Jose M Olalla
- Department of Pathology, Servicio de Salud de Castilla-La Mancha, Hospital La Mancha Centro, Ciudad Real, Spain
| | - Laura A Vinson
- Gastroenterology Division, University of Utah School of Medicine, Salt Lake City, Utah
| | - Amy Lowichik
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah; Department of Pathology, Primary Children's Hospital, Salt Lake City, Utah
| | - Xinjian Chen
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Lyska Emerson
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Kristen Cox
- Gastroenterology Division, University of Utah School of Medicine, Salt Lake City, Utah
| | - Molly A O'Gorman
- Gastroenterology Division, University of Utah School of Medicine, Salt Lake City, Utah; Division of Gastroenterology, Primary Children's Hospital, Salt Lake City, Utah
| | - Kathryn A Peterson
- Gastroenterology Division, University of Utah School of Medicine, Salt Lake City, Utah
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22
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Murphy CJ, Cox K, Fang JC. “Cat Scratch Colon” and Cecal Barotrauma perforation during colonoscopy using CO 2 insufflation. SAGE Open Med Case Rep 2014; 2:2050313X14550359. [PMID: 27489654 PMCID: PMC4857357 DOI: 10.1177/2050313x14550359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 08/11/2014] [Indexed: 11/17/2022] Open
Abstract
Cecal perforation due to barotrauma is an increasingly recognized complication of colonoscopy when using room air for insufflation. CO2 is increasingly being utilized for insufflation due to more rapid absorption compared to ambient air and results in reduced post-procedural pain and flatulence. Use of CO2 is thought to protect against barotrauma injury, and use of CO2 during endoscopy has not previously been reported to cause barotrauma perforation during colonoscopy. We present a case of cecal perforation secondary to barotrauma during routine screening colonoscopy with CO2.
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Affiliation(s)
- Christopher John Murphy
- Division of Gastroenterology and Hepatology, The Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kristen Cox
- Division of Gastroenterology and Hepatology, The Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - John C Fang
- Division of Gastroenterology and Hepatology, The Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Peterson KA, Byrne KR, Vinson LA, Ying J, Boynton KK, Fang JC, Gleich GJ, Adler DG, Clayton F. Elemental diet induces histologic response in adult eosinophilic esophagitis. Am J Gastroenterol 2013; 108:759-66. [PMID: 23381017 DOI: 10.1038/ajg.2012.468] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Elemental diets have not been studied in adults with eosinophilic esophagitis (EoE). The goal of this trial was to assess the efficacy of an elemental diet in adults with EoE. METHODS A total of 18 adults with EoE were given an elemental diet for 4 weeks, or just 2 weeks if their response was complete. Symptoms and histologic findings, based on biweekly biopsies, were monitored. Six subjects were rebiopsied 2-7 days after resuming a normal diet. RESULTS After therapy, esophageal tissue eosinophil content decreased from 54 to 10 per maximal high power field (P=0.0006). There was complete or nearly complete response (≤10 eosinophils) in 72% of subjects. Mast cell content, parabasal layer thickness, and endoscopic furrows and exudates also significantly decreased. Of the 29 qualified subjects, 11 (38%) failed to adhere to the diet. Several subjects had significant weight loss. Symptoms and endoscopic fixed strictures did not improve. After the subjects resumed a normal diet, the eosinophil content increased substantially in 3-7 days. CONCLUSIONS While symptoms did not improve and dietary compliance was problematic, there was substantial histologic improvement after 4 weeks on the elemental diet. EoE in adults is substantially triggered by foods.
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Affiliation(s)
- Kathryn A Peterson
- Department of Gastroenterology, University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
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Fang JC, DeMarco T, Givertz MM, Borlaug BA, Lewis GD, Rame JE, Gomberg-Maitland M, Murali S, Frantz RP, McGlothlin D, Horn EM, Benza RL. Errata. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2012.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Kawa C, Adler DG, Hilden K, Tietze C, Bromberg MB, Fang JC. Response to Vianello et al. Nutr Clin Pract 2013; 28:144. [PMID: 23319357 DOI: 10.1177/0884533612470699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Feeding tube placement for enteral nutrition (EN) support is widely used in both critically ill and stable chronically ill patients who are unable to meet their nutrition needs orally. Nasal or oral feeding tubes can be performed blindly at the bedside or with fluoroscopic or endoscopic guidance into the stomach or small bowel. Percutaneous feeding tubes are used when EN support is required for longer periods (>4-6 weeks) and are most commonly placed endoscopically or radiographically. Although generally safe and effective, there is a wide spectrum of known complications associated with feeding tube placement. Errors made at the time of feeding tube placement can result in a number of these procedural and postprocedural complications. In many cases, a single error at the time of placement can result in numerous complications. A thorough knowledge of these errors and avoiding them in practice will decrease iatrogenic complications in a vulnerable population. In addition, early recognition and management of complications will further minimize morbidity and even mortality in enteral feeding tube placement. This article reviews the common errors leading to complications of enteral feeding tube placement and their prevention and management.
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Affiliation(s)
- James L Stayner
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah 84132, USA
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Tuteja AK, Fang JC, Al-Suqi M, Stoddard GJ, Hale DC. Double-blind placebo-controlled study of mesalamine in post-infective irritable bowel syndrome--a pilot study. Scand J Gastroenterol 2012; 47:1159-64. [PMID: 22783919 DOI: 10.3109/00365521.2012.694903] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Post-infective irritable bowel syndrome (PI-IBS) is characterized by continuing symptoms of irritable bowel syndrome, typically diarrhea-predominant, following an episode of acute gastroenteritis. There is often an increase in sub-epithelial inflammatory and neuroendocrine cells on colonic mucosal biopsy. Mesalamine is an anti-inflammatory agent, effective in the treatment of inflammatory bowel disease. The goal of this study was to compare mesalamine to placebo on symptoms and quality-of-life (QOL) in PI-IBS. MATERIAL AND METHODS Twenty patients who developed diarrhea-predominant IBS after gastroenteritis were randomized to receive mesalamine (Asacol®) 1.6 gm b.i.d. or placebo for 12 weeks in a double-blind placebo-controlled study. QOL was assessed using the IBS-QOL questionnaire. Stool frequency, stool consistency, urgency, severity of abdominal pain, severity of bloating, and global-improvement scale were recorded in daily diaries for 7 days at baseline and every 4 weeks. Data were analyzed by comparing the change from baseline to last follow-up. RESULTS One patient withdrew after randomization; data were incomplete in two patients. Thus, data were analyzed from 17 patients (11 men and 6 women, median age: 27 years, range 22-45 years). Mesalamine was not associated with significant improvement in global symptoms, abdominal pain, bloating, stool urgency, frequency, or consistency (all p ≥ 0.11) or QOL (p ≥ 0.16). CONCLUSIONS There was no significant improvement in global symptoms or overall QOL with mesalamine in patients with PI-IBS.
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Affiliation(s)
- Ashok K Tuteja
- Division of Gastroenterology, University of Utah, School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA.
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Kawa C, Stewart J, Hilden K, Adler DG, Tietze C, Bromberg MB, Fang JC. A Retrospective Study of Nurse-Assisted Propofol Sedation in Patients With Amyotrophic Lateral Sclerosis Undergoing Percutaneous Endoscopic Gastrostomy. Nutr Clin Pract 2012; 27:540-4. [PMID: 22645103 DOI: 10.1177/0884533612443712] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Chad Kawa
- University Hospitals Case Medical Center, Cleveland, Ohio
| | - James Stewart
- Carl T. Hayden Veterans Affairs Medical Center, Phoenix, Arizona
| | - Kristen Hilden
- University of Utah, Division of Gastroenterology, Salt Lake City, Utah
| | - Douglas G. Adler
- University of Utah, Division of Gastroenterology, Salt Lake City, Utah
| | | | | | - John C. Fang
- University of Utah, Division of Gastroenterology, Salt Lake City, Utah
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Steenblik M, Hilden K, Fang JC. A retrospective correlation of percutaneous feeding tube stoma length in sitting and supine positions compared with body mass index. Nutr Clin Pract 2012; 27:406-9. [PMID: 22402408 DOI: 10.1177/0884533612438406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Accurate knowledge of stoma tract length is important to prevent gastric ulcer formation, buried bumper syndrome, and peristomal leakage/infection. Current guidelines suggest 0.5-1.0 cm of play between the skin and external bolster. The aim of this study was to determine if stoma tract length changes from supine and sitting position and if this change is related to BMI. METHODS Patients undergoing percutaneous feeding tube change from November 2006 to September 2009 were enrolled. Correlations were made between BMI and stoma tract length in both sitting and supine positions. RESULTS Twenty-eight patients (24 percutaneous endoscopic gastrostomy [PEG], 4 direct percutaneous jejunal feeding tube) were included; 19 (68%) were female. The mean ± SD stoma length was 3.6 ± 0.9 cm in the supine position and 4.9 ± 1.4 cm in the sitting position. The mean ± SD stoma length change from supine to sitting position was 1.53 ± 0.9 cm. Mean ± SD BMI was 21.2 ± 4.5 (range, 14.9-33.8). Stoma length in the supine position (r = 0.65, P = .0002) and sitting position (r = 0.6, P = .0009) was strongly correlated with BMI. Change in stoma tract length was correlated with BMI (r = 0.43, P = .02). CONCLUSION Stoma tract length is strongly correlated with BMI in both the sitting and supine positions. PEG stoma tract length changes significantly from the supine and sitting position. To prevent complications, most patients should have a longer distance set between internal and external bolsters than is recommended.
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Warren JD, Xiong W, Bunker AM, Vaughn CP, Furtado LV, Roberts WL, Fang JC, Samowitz WS, Heichman KA. Septin 9 methylated DNA is a sensitive and specific blood test for colorectal cancer. BMC Med 2011; 9:133. [PMID: 22168215 PMCID: PMC3271041 DOI: 10.1186/1741-7015-9-133] [Citation(s) in RCA: 294] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 12/14/2011] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND About half of Americans 50 to 75 years old do not follow recommended colorectal cancer (CRC) screening guidelines, leaving 40 million individuals unscreened. A simple blood test would increase screening compliance, promoting early detection and better patient outcomes. The objective of this study is to demonstrate the performance of an improved sensitivity blood-based Septin 9 (SEPT9) methylated DNA test for colorectal cancer. Study variables include clinical stage, tumor location and histologic grade. METHODS Plasma samples were collected from 50 untreated CRC patients at 3 institutions; 94 control samples were collected at 4 US institutions; samples were collected from 300 colonoscopy patients at 1 US clinic prior to endoscopy. SEPT9 methylated DNA concentration was tested in analytical specimens, plasma of known CRC cases, healthy control subjects, and plasma collected from colonoscopy patients. RESULTS The improved SEPT9 methylated DNA test was more sensitive than previously described methods; the test had an overall sensitivity for CRC of 90% (95% CI, 77.4% to 96.3%) and specificity of 88% (95% CI, 79.6% to 93.7%), detecting CRC in patients of all stages. For early stage cancer (I and II) the test was 87% (95% CI, 71.1% to 95.1%) sensitive. The test identified CRC from all regions, including proximal colon (for example, the cecum) and had a 12% false-positive rate. In a small prospective study, the SEPT9 test detected 12% of adenomas with a false-positive rate of 3%. CONCLUSIONS A sensitive blood-based CRC screening test using the SEPT9 biomarker specifically detects a majority of CRCs of all stages and colorectal locations. The test could be offered to individuals of average risk for CRC who are unwilling or unable to undergo colonscopy.
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Affiliation(s)
- Jorja D Warren
- New Technology Group, ARUP Laboratories, Inc., 500 Chipeta Way, Mail Code 209, Salt Lake City, UT 84108-1221, USA
| | - Wei Xiong
- New Technology Group, ARUP Laboratories, Inc., 500 Chipeta Way, Mail Code 209, Salt Lake City, UT 84108-1221, USA
| | - Ashley M Bunker
- ARUP Institute of Experimental Pathology, ARUP Laboratories, Inc., 500 Chipeta Way, Salt Lake City, UT 84108-1221, USA
| | - Cecily P Vaughn
- ARUP Institute of Experimental Pathology, ARUP Laboratories, Inc., 500 Chipeta Way, Salt Lake City, UT 84108-1221, USA
| | - Larissa V Furtado
- University of Utah Department of Pathology, ARUP Laboratories, Inc., 500 Chipeta Way, Salt Lake City, UT 84108-1221, USA
| | - William L Roberts
- University of Utah Department of Pathology, ARUP Laboratories, Inc., 500 Chipeta Way, Salt Lake City, UT 84108-1221, USA
| | - John C Fang
- Divison of Gastroenterology, University School of Utah Medicine, 30N 1900 E, Room 4R118, salt Lake City, UT 84132, USA
| | - Wade S Samowitz
- University of Utah Department of Pathology, ARUP Laboratories, Inc., 500 Chipeta Way, Salt Lake City, UT 84108-1221, USA
| | - Karen A Heichman
- New Technology Group, ARUP Laboratories, Inc., 500 Chipeta Way, Mail Code 209, Salt Lake City, UT 84108-1221, USA
- University of Utah Department of Pathology, ARUP Laboratories, Inc., 500 Chipeta Way, Salt Lake City, UT 84108-1221, USA
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Nishiwaki S, Araki H, Fang JC, Hayashi M, Takada J, Iwashita M, Tagami A, Hatakeyama H, Hayashi T, Maeda T, Saito K. Retrospective analyses of complications associated with transcutaneous replacement of percutaneous gastrostomy and jejunostomy feeding devices. Gastrointest Endosc 2011; 74:784-91. [PMID: 21802678 DOI: 10.1016/j.gie.2011.05.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Accepted: 05/19/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Feeding device replacement is often required for long-term maintenance after initial percutaneous endoscopic gastrostomy or jejunostomy placement. Although there are several case reports on serious complications of gastrostomy device replacement, there are few reports of an overall analysis of the complications associated with feeding device replacement. OBJECTIVE To evaluate the frequency and variety of complications of transcutaneous replacement of feeding devices. DESIGN A retrospective study. SETTING Single center: Nishimino Kosei Hospital. PATIENTS This study involved 363 consecutive patients undergoing a total of 1265 percutaneous gastrostomy or jejunostomy device replacements from March 2000 to September 2010. INTERVENTION A new replacement device was inserted through the ostomy tract by using an obturator after traction removal of the previous device. Endoscopic treatments were performed in the cases of fistula disruption or hemorrhage. MAIN OUTCOME MEASUREMENTS Complications and their outcomes. RESULTS Gastrostomy and jejunostomy devices were replaced 1126 and 139 times, respectively. There were 16 complications (1.3% of total replacements) consisting of 10 cases of fistula disruption caused by misplacement of replacement devices into the peritoneal cavity, 4 cases of hemorrhage, and 1 case each of colocutaneous fistula and device breakage. Anticoagulation or antiplatelet medications were continued in all 4 hemorrhage cases but in only 27 of 347 (7.7%) complication-free cases (P < .0001). There were no replacement-related adverse events that required surgical repair. LIMITATIONS A single center, retrospective analysis. CONCLUSION Fistula disruption and hemorrhage were the most common complications associated with device replacement. In patients on anticoagulants, caution is necessary to avoid hemorrhage after replacement. It is also important to verify that the replaced device is located in the GI tract lumen before feeding.
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Affiliation(s)
- Shinji Nishiwaki
- Department of Internal Medicine, Nishimino Kosei Hospital, Yoro-gun, Gifu, Japan
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Itkin M, DeLegge MH, Fang JC, McClave SA, Kundu S, d'Othee BJ, Martinez-Salazar GM, Sacks D, Swan TL, Towbin RB, Walker TG, Wojak JC, Zuckerman DA, Cardella JF. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Gastroenterology 2011; 141:742-65. [PMID: 21820533 DOI: 10.1053/j.gastro.2011.06.001] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 04/08/2011] [Indexed: 02/06/2023]
Affiliation(s)
- Maxim Itkin
- Department of Radiology, Division of Interventional Radiology, University of Pennsylvania Medical Center, Pennsylvania Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
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Maxwell CI, Hilden K, Glasgow RE, Ollerenshaw J, Carlisle JG, Fang JC. Evaluation of gastropexy and stoma tract maturation using a novel introducer kit for percutaneous gastrostomy in a porcine model. JPEN J Parenter Enteral Nutr 2011; 35:630-5. [PMID: 21765053 DOI: 10.1177/0148607111413596] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Fluoroscopic placement of percutaneous gastrostomy (PG) requires the use of T-bar fasteners to affix the stomach to the anterior abdominal wall; the effect of T-fasteners on stoma tract maturation is unknown. The authors studied PG stoma tract maturation, comparing PG + gastropexy with standard percutaneous endoscopic gastrostomy (PEG). METHODS Sixteen pigs underwent PG placement using a novel introducer kit. Three absorbable suture T-fasteners were placed around the stoma site, and PG was placed using the Russell method. A standard PEG was then placed using the Ponsky pull method, allowing each animal to serve as its own control. Gross and histopathological integrity of stoma tract formation was assessed at 1-3 weeks. RESULTS At sacrifice, all PGs were intact with no evidence of infection, disruption, or significant leakage. Stoma tracts of all test and control sites were robust and histologically mature at all time points. Stoma tract diameters were also similar between test and control PGs (mean ± SEM: control 13.1 ± 0.7 mm, test 12.1 ± 0.4 mm; P = .2, n = 15). Histopathological evaluation demonstrated a generally comparable tissue response between test and control PGs, with slight decreases in fibrosis noted in test compared to control sites (P = .02, n = 15). CONCLUSIONS Stoma tract maturation of PG with gastropexy provides similar results to standard PEG. Stoma tracts were mature at 1 week regardless of placement method. Placement and performance of PG using the new introducer kit with novel T-fasteners and absorbable suture yields effective gastric anchoring and has similar ease of use as standard PEG placement.
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Krishnamurthy C, Hilden K, Peterson KA, Mattek N, Adler DG, Fang JC. Endoscopic findings in patients presenting with dysphagia: analysis of a national endoscopy database. Dysphagia 2011; 27:101-5. [PMID: 21674194 DOI: 10.1007/s00455-011-9346-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 05/20/2011] [Indexed: 11/26/2022]
Abstract
Dysphagia is a common problem and an indication for upper endoscopy. There is no data on the frequency of the different endoscopic findings and whether they change according to demographics or by single versus repeat endoscopy. To determine the prevalence of endoscopic findings in patients with dysphagia and whether findings differ in regard to age, gender, ethnicity, and repeat procedure. This was a retrospective study using a national endoscopic database (CORI). A total of 30,377 patients underwent esophagogastroduodenoscopy (EGD) for dysphagia of which 4,202 patients were repeat endoscopies. Overall frequency of endoscopic findings was determined by gender, age, ethnicity, and single vs. repeat procedures. Esophageal stricture was the most common finding followed by normal, esophagitis/ulcer (EU), Schatzki ring (SR), esophageal food impaction (EFI), and suspected malignancy. Males were more likely to undergo repeat endoscopies and more likely to have stricture, EU, EFI, and suspected malignancy (P = 0.001). Patients 60 years or older had a higher prevalence of stricture, EU, SR, and suspected malignancy (P < 0.0001). Esophageal stricture was most common in white non-Hispanic patients compared to other ethnic groups. In patients undergoing repeat EGD, stricture, SR, EFI, and suspected malignancy were more common (P < 0.0001). The prevalence of endoscopic findings differs significantly by gender, age, and repeat procedure. The most common findings in descending order were stricture, normal, EU, SR, EFI, and suspected malignancy. For patients undergoing a repeat procedure, normal and EU were less common and all other abnormal findings were significantly more common.
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Affiliation(s)
- Chaya Krishnamurthy
- Division of Gastroenterology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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Abstract
Expertise in enteral nutrition (EN) is an important aspect of the skill set of the clinical gastroenterologist. Delivery of adequate EN in critically ill patients is an active therapy that attenuates the metabolic response to stress and favorably modulates the immune system. EN is less expensive than parenteral nutrition and is favored in most cases because of improvement in patient outcomes, including infections and length of stay. Newer endoscopic techniques for placing nasoenteric feeding tubes have been developed, which improve placement success and efficiency. It appears that there is an ideal window period of 24-48 h when enteral feeding should be started in critically ill patients. Most patients can be fed into the stomach, but certain groups may benefit from small bowel feeding. Protocols on how to start and monitor enteral feeding have been developed. Immune-modulating feeding formulations also appear to be beneficial in specific patient populations. The gastroenterologist is a crucial member of the multidisciplinary team for nutritional support in the intensive care unit patient, with his knowledge of gastrointestinal pathophysiology, nutrition, and endoscopic feeding-tube placement.
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Affiliation(s)
- John C Fang
- Department of Gastroenterology, University of Utah Health Sciences, Salt Lake City, Utah, USA.
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Holmes KP, Fang JC, Jackson BR. Cost-effectiveness of six strategies for Helicobacter pylori diagnosis and management in uninvestigated dyspepsia assuming a high resource intensity practice pattern. BMC Health Serv Res 2010; 10:344. [PMID: 21176158 PMCID: PMC3022876 DOI: 10.1186/1472-6963-10-344] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 12/21/2010] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Initial assessment of dyspepsia often includes noninvasive testing for Helicobacter pylori infection. Commercially available tests vary widely in cost and accuracy. Although there is extensive literature on the cost-effectiveness of H. pylori treatment, there is little information comparing the cost-effectiveness of various currently used, noninvasive testing strategies. METHODS A Markov simulation was used to calculate cost per symptom-free year and cost per correct diagnosis. Uncertainty in outcomes was estimated using probabilistic sensitivity analysis. RESULTS Under the baseline assumptions, cost per symptom-free year was $122 for empiric proton pump inhibitor (PPI) trial, and costs for the noninvasive test strategies ranged from $123 (stool antigen) to $129 (IgG/IgA combined serology). Confidence intervals had significant overlap. CONCLUSIONS Under our assumptions for how testing for H. pylori infection is employed in United States medical practice, the available noninvasive tests all have similar cost-effectiveness between one another as well as with empiric PPI trial.
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Buchman AL, Katz S, Fang JC, Bernstein CN, Abou-Assi SG. Teduglutide, a novel mucosally active analog of glucagon-like peptide-2 (GLP-2) for the treatment of moderate to severe Crohn's disease. Inflamm Bowel Dis 2010; 16:962-73. [PMID: 19821509 DOI: 10.1002/ibd.21117] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Teduglutide, an analog of glucagon-like peptide-2 (GLP-2), is associated with trophic effects on gut mucosa. Its role in the treatment of active Crohn's disease (CD) was assessed in a pilot, randomized, placebo-controlled, double-blinded, dose-ranging study. METHODS Subjects with moderate-to-severe CD were randomized 1:1:1:1 to placebo or 1 of 3 doses of teduglutide (0.05, 0.10, or 0.20 mg/kg daily) delivered as a daily subcutaneous injection for 8 weeks. The primary outcome measure was the percentage of subjects in each group that responded to treatment, defined as a decrease in Crohn's Disease Activity Index (CDAI) score to <150 or a decrease of > 100 points. At week 8 there was an optional 12-week open-label period of treatment with teduglutide 0.10 mg/kg/d. RESULTS One hundred subjects were enrolled and 71 completed the study. The mean baseline CDAI score was 290.8 +/- 57.6 and was similar across groups. There were numerically higher response and remission rates in all teduglutide-treated groups as compared with placebo, although the percentage of subjects who achieved a clinical response or remission was more substantial, and seen as early as week 2 of treatment in the highest dose (0.2 mg/kg/d) group (44% response and 32% remission versus 32% response and 20% remission in the placebo group). Of subjects who had not achieved remission during the 8-week placebo-controlled phase in the higher-dose group, 50% achieved remission during the more prolonged, open-label treatment phase. Plasma citrulline was similar across groups at baseline, but increased substantially over time in all teduglutide groups when compared with placebo at week 8. Adverse events were not different between placebo and active treatment groups. CONCLUSIONS Teduglutide is a novel and potentially effective therapy for inducing remission and mucosal healing in patients with active moderate-to-severe CD. Further clinical investigation of this growth factor is warranted.
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Affiliation(s)
- Alan L Buchman
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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Adler DG, Hilden K, Wills JC, Quinney E, Fang JC. What drives US gastroenterology fellows to pursue academic vs. non-academic careers?: Results of a national survey. Am J Gastroenterol 2010; 105:1220-3. [PMID: 20523306 DOI: 10.1038/ajg.2010.101] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We conducted a nationwide survey of US gastroenterology fellows to identify key demographic and job-related factors relevant to the decision between an academic and a non-academic career. METHODS A survey was e-mailed to all US GI fellowship program directors and distributed at fellows' endoscopy courses. Data were evaluated via univariate and multivariate analysis. RESULTS One hundred eighty-four fellows completed surveys. Univariate analysis identified one factor that predisposed fellows to pursue non-academic practice: the perception that a non-academic salary would meet their financial needs. Four factors were identified that predisposed fellows to pursue academic practice: age>35 years, prior attainment of a master's or a PhD degree, and advanced fellowship. All factors were significant on multivariate analysis. If salaries were equal, 60% of respondents would choose academic over non-academic practice. Fellows selecting academic practice were motivated to publish and conduct research. Level of debt and a positive relationship with a mentor were not significant factors. CONCLUSIONS Fellows desiring more money strongly favor non-academic practice. Fellows choosing academic practice tend to be older, plan to pursue advanced training, desire fewer work hours per week, and have a higher rate of prior graduate study. If salaries were equal in academic medicine and non-academic practice, the majority of fellows would choose academic medicine.
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Affiliation(s)
- Douglas G Adler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA.
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Peterson KA, Samuelson WM, Ryujin DT, Young DC, Thomas KL, Hilden K, Fang JC. The role of gastroesophageal reflux in exercise-triggered asthma: a randomized controlled trial. Dig Dis Sci 2009; 54:564-71. [PMID: 18688720 DOI: 10.1007/s10620-008-0396-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 06/18/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Exercise-triggered asthma (ETA) develops when physical activity triggers asthma symptoms during or directly after exercise. In patients prone to symptoms of supra-esophageal reflux, exercise may trigger gastroesophageal reflux (GER), resulting in such symptoms. AIMS To determine the prevalence of abnormal pH in patients with ETA and to determine whether acid suppression improves symptoms in ETA patients. METHODS We performed a randomized double-blind trial of rabeprazole versus placebo in the treatment of patients with ETA. Patients underwent treadmill protocol to determine their VO(2 max). Next, pH testing was initiated while undergoing a 30-min treadmill program exercising them at 65% of their VO(2 max). They were subsequently randomized to rabeprazole or placebo for 10 weeks. At the end of 10 weeks, exercise testing was repeated. RESULTS A total of 31 patients completed the study (20 asthmatics, 11 non-asthmatics). Twenty-two out of 30 (73%) subjects had abnormal pH studies. For all subjects, rabeprazole improved symptoms more than placebo (P = 0.03). The association was stronger in the pH-positive group (P = 0.009). CONCLUSION Acid reflux is common in ETA patients. Many patients with exercise-related respiratory symptoms are misdiagnosed as chronic asthmatics. Exercise-related symptoms improve with the use of acid suppression. This study suggests that ETA patients may benefit from acid suppression.
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Affiliation(s)
- Kathryn A Peterson
- Division of Gastroenterology, University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA.
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Neklason DW, Thorpe BL, Ferrandez A, Tumbapura A, Boucher K, Garibotti G, Kerber RA, Solomon CH, Samowitz WS, Fang JC, Mineau GP, Leppert MF, Burt RW, Kuwada SK. Colonic adenoma risk in familial colorectal cancer--a study of six extended kindreds. Am J Gastroenterol 2008; 103:2577-84. [PMID: 18671820 PMCID: PMC2922112 DOI: 10.1111/j.1572-0241.2008.02019.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Most colorectal cancers (CRCs) arise from adenomatous polyps, but the effects of CRC family history on adenoma risk are not well known. This issue is clinically relevant since several medical societies currently recommend earlier and more rigorous colorectal screening for individuals with a strong family history of CRC. METHODS Colonoscopies were performed in 236 first-, second-, and third-degree relatives of 40 index CRC cases from six large kindreds selected from a large population database. The kindreds were selected for significantly greater risk of CRCs compared with the overall population. Known hereditary colon cancer syndromes were clinically and genetically excluded. RESULTS Thirty-seven percent of relatives were found to have adenomas on colonoscopy. The average age of diagnosis for colon cancer was 63 yr and advanced adenomas 56 yr. Independent predictors of adenomatous polyps in the relatives were advancing age (P < 0.0001), male gender (P < 0.001), and greater degree of relation to CRC cases (P < 0.01). There was no significant predilection of colorectal tumors for the right or left colon. A higher degree of relationship to CRC cases was a significant predictor of having simple and advanced adenomas, but not hyperplastic polyps after adjustment for age and gender. CONCLUSIONS These data support the current recommendations for colonoscopy starting before the age of 50 yr in individuals with a strong family history of CRC.
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Affiliation(s)
- Deborah W. Neklason
- Huntsman Cancer Institute, Salt Lake City, Utah,Oncological Sciences, Salt Lake City, Utah
| | | | | | | | - Kenneth Boucher
- Huntsman Cancer Institute, Salt Lake City, Utah,Oncological Sciences, Salt Lake City, Utah
| | | | - Richard A. Kerber
- Huntsman Cancer Institute, Salt Lake City, Utah,Oncological Sciences, Salt Lake City, Utah
| | | | | | | | - Geraldine P. Mineau
- Huntsman Cancer Institute, Salt Lake City, Utah,Oncological Sciences, Salt Lake City, Utah
| | | | - Randall W. Burt
- Huntsman Cancer Institute, Salt Lake City, Utah,Dept. of Medicine, Salt Lake City, Utah
| | - Scott K. Kuwada
- Huntsman Cancer Institute, Salt Lake City, Utah,Oncological Sciences, Salt Lake City, Utah,Dept. of Medicine, Salt Lake City, Utah,University of Utah and Veterans Administration Health Care System, Salt Lake City, Utah,To whom correspondence should be sent: Scott Kuwada, M.D. Huntsman Cancer Institute 2000 Circle of Hope Salt Lake City, Utah 84112-5550 (801)585-0303 phone
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Abstract
Percutaneous endoscopic gastrostomy (PEG) or PEG tube with transgastric jejunostomy tube (PEG-J) feeding has not been shown to decrease aspiration pneumonia. The aim of this study was to determine if direct percutaneous endoscopic jejunostomy (DPEJ) tube placement results in a decreased incidence of aspiration pneumonia in high-risk patients. The design was a retrospective review of all patients receiving DPEJ tube for aspiration pneumonia from 1999 to 2005. Demographics, incidence of aspiration pneumonia, and outcomes were collected and compared before and after the DPEJ placement. Eleven patients (4 women, 7 men) were identified; their mean age was 44.9 years (range, 18-94 years). The etiologies for recurrent aspiration pneumonia were neurologic disease (9), esophageal surgery (1), and severe debilitation (1). The mean follow-up was 20.9 months (range, 6-48 months). The patients' mean weight increased from 43.8 kg (range, 19-55 kg) to 48.3 kg (range, 30-65 kg) after placement (P < .001). The total number of documented aspiration pneumonia episodes for all patients decreased from 29 (mean, 3.64; range, 1-6) before DPEJ placement to 3 (mean, 0.27; range, 0-2) after DPEJ placement (P < .001). The mean number of aspiration pneumonia events per month prior to the DPEJ placement was 3.39 and postplacement was 0.42 (P < .001). DPEJ placement appears to decrease recurrent aspiration pneumonia in patients with history of aspiration pneumonia.
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Affiliation(s)
- Panagiotis H Panagiotakis
- Division of Gastroenterology and Hepatology, University of Utah, 4R118 School of Medicine, Salt Lake City, UT 84132, USA
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Wills JC, Hilden K, Disario JA, Fang JC. A randomized, prospective trial of electrosurgical incision followed by rabeprazole versus bougie dilation followed by rabeprazole of symptomatic esophageal (Schatzki's) rings. Gastrointest Endosc 2008; 67:808-13. [PMID: 18313671 DOI: 10.1016/j.gie.2007.10.062] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Accepted: 10/30/2007] [Indexed: 12/26/2022]
Abstract
BACKGROUND Lower esophageal (Schatzki's) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring, but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement. There are no data on the treatment of Schatzki's rings in the presence of acid suppression treatment. OBJECTIVE Our purpose was to compare the efficacy of bougie dilation with electrosurgical incision of symptomatic Schatzki's rings at 1-year follow-up in the presence of rabeprazole treatment. DESIGN Randomized, prospective trial. SETTING University of Utah Health Sciences Center and the Veterans Affairs Salt Lake. PATIENTS Fifty patients referred for endoscopic evaluation of dysphagia between January 2002 and March 2005. MAIN OUTCOME MEASUREMENTS Symptom-free survival time (in months), dysphagia, and GERD scores. RESULTS Twenty-five patients each underwent bougie dilation and electrical incision and were followed up for 12 months. Symptom-free survival times were significantly longer in the incision group (7.99 months) compared with the bougie dilation group (5.86 months) (P = .03). Dysphagia and GERD scores significantly improved in each group comparing baseline with each time interval. The incision group had greater relief of dysphagia at 1 month (P = .05) compared with the bougie group. There was no difference between GERD scores in both groups. LIMITATIONS Dysphagia and GERD symptoms were self-reported. CONCLUSIONS Electrosurgical incision of Schatzki's rings is safe and offers longer symptom-free survival compared with bougie dilation. The addition of rabeprazole offered significant improvement in GERD scores in both groups.
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Affiliation(s)
- Jason C Wills
- Division of Gastroenterology, University of Utah Health Sciences Center, Salt Lake City, Utah 84132, USA
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Virnig DJ, Frech EJ, Delegge MH, Fang JC. Direct percutaneous endoscopic jejunostomy: a case series in pediatric patients. Gastrointest Endosc 2008; 67:984-7. [PMID: 18308316 DOI: 10.1016/j.gie.2007.11.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Accepted: 11/12/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Direct percutaneous endoscopic jejunostomy (DPEJ) is a well-known approach to deliver postpyloric enteral nutrition support to individuals who cannot tolerate gastric feeding. DPEJ addresses many of the shortcomings of jejunal feeding tubes placed through percutaneous endoscopic gastrostomy tubes. The safety and efficacy of DPEJ in adults has been previously reported. There are no reports on the use of DPEJ in pediatric patients. OBJECTIVE Our purpose was to report on 5 pediatric patients who underwent DPEJ placement between January 2000 and January 2003 over the available follow-up periods. DESIGN Retrospective case series. SETTING University of Utah Health Sciences Center and the Medical University of South Carolina. PATIENTS Five patients, age range 4 to 17 years. MAIN OUTCOME MEASUREMENTS Rate of successful tube placement, major and minor complications, and outcomes including weight gain and recurrent aspiration after DPEJ placement. RESULTS All 5 attempted DPEJs were placed successfully with 2 minor complications of peristomal leakage and peristomal skin infection. One DPEJ was replaced 2 years after placement because of fungal degradation. The mean weight gain among all patients was 10.3 kg in a mean of 22.6 months. LIMITATIONS Retrospective, small series. CONCLUSIONS DPEJ placement appears to be a safe and effective approach to enteral nutritional support in pediatric patients requiring long-term access to the jejunum. No major complications occurred and all patients gained weight after tube placement.
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Affiliation(s)
- Daniel J Virnig
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah 84132, USA
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Mackenzie SH, Haslem D, Hilden K, Thomas KL, Fang JC. Success rate of direct percutaneous endoscopic jejunostomy in patients who are obese. Gastrointest Endosc 2008; 67:265-9. [PMID: 17996236 DOI: 10.1016/j.gie.2007.06.041] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Accepted: 06/18/2007] [Indexed: 01/24/2023]
Abstract
BACKGROUND Direct percutaneous endoscopic jejunostomy (DPEJ) is increasingly used as a method for obtaining jejunal enteral access. The most cited reason of unsuccessful placement is poor transillumination, which may be related to obesity. Whether obesity affects failure and complication rates has not been previously described. OBJECTIVE To compare the success rate and adverse events (AEs) associated with DPEJ placement in patients who were overweight and patients who were obese compared with patients who were normal or underweight defined by body mass index (BMI). DESIGN Retrospective database review. SETTING A tertiary-referral center. PATIENTS Eighty DPEJ placements between February 2000 and September 2005. MAIN OUTCOME MEASUREMENTS DPEJ placement success in patients who were overweight/obese (BMI >or= 25) versus patients who were normal or underweight (BMI <25). Secondary end points included procedure time and AEs. RESULTS Eighty DPEJs were placed in 75 patients. Of these DPEJs, 65 (81%) succeeded and 15 (19%) failed. Success rates were 23 of 24 for patients who were underweight (96%), 25 of 31 for patients with normal BMI (81%), 8 of 11 for patients who were overweight (73%), and 6 of 10 for persons who were obese (60%) (odds ratio 3.43, 95% CI 1.03-11.44; P< .05 for BMI >or= 25 vs BMI<25). Overall, AEs were not significantly different for patients with BMI <25 versus BMI >or=25 (24/55 vs 9/21, respectively; P= .64). However, 4 of the 5 severe AEs occurred in patients with a BMI >or= 25 (P= .07). LIMITATIONS Retrospective single center. CONCLUSIONS DPEJ placement in patients who were overweight or obese was feasible, but procedural success was less frequent, and a trend toward more frequent major AEs was seen than in persons with normal or decreased BMI. BMI was an easily assessed preprocedural factor for DPEJ success and complication rates.
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Affiliation(s)
- Scott H Mackenzie
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah 84132, USA
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Abstract
Until recently, esophageal stents have not been a realistic option for the management of benign disease owing to difficulty removing the stents and associated high complication rates. However, progress in esophageal stent design has led to the development of retrievable esophageal stents. Clinical experience has shown promise for the management of benign esophageal diseases with retrievable stents, including refractory strictures, esophageal leaks, fistula and perforations. They have been shown to be safe and effective, though stent migration remains a concern. This article reviews the current designs, indications, efficacy and complications of retrievable esophageal stents.
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Affiliation(s)
- Robert F Wong
- University of Utah School of Medicine, 30 North 1900 East, 4R118 School of Medicine, Salt Lake City, UT 84132, USA.
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Abstract
Enteral nutrition support is preferred to parenteral or no nutritional support, but many patients who could benefit receive inadequate enteral feeding. Many decisions must be made before initiating enteral nutrition support; including if and when enteral nutrition should be started, which formula should be used, and how enteral nutrition support should be monitored. The gastroenterologist should be able to understand and evaluate these decisions in all patients potentially requiring nutritional support.
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Affiliation(s)
- Casey Owens
- Department of Internal Medicine, University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
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Mackenzie SH, Fang JC, Kuwada SK. Severe upper-GI bleeding in a patient with PEG tube placement by the radiologic push method. Gastrointest Endosc 2007; 65:935-7. [PMID: 17382941 DOI: 10.1016/j.gie.2006.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 09/20/2006] [Indexed: 12/10/2022]
Affiliation(s)
- Scott H Mackenzie
- Division of Gastroenterology, Department of Medicine, University of Utah, Veterans Affairs Health Care System, Salt Lake City, Utah, USA
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Goulet CJ, Disario JA, Emerson L, Hilden K, Holubkov R, Fang JC. In vivo evaluation of argon plasma coagulation in a porcine model. Gastrointest Endosc 2007; 65:457-62. [PMID: 17321247 DOI: 10.1016/j.gie.2006.09.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Accepted: 09/07/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND Argon plasma coagulation (APC) is a noncontact form of monopolar electrocautery. One purported advantage of APC includes a limit to the depth of injury. It is unclear from previous studies whether the depth of injury is limited to superficial tissue layers with the settings used in clinical practice. OBJECTIVE To evaluate the depth and the area of APC-induced injury by using new modes of APC delivery in an in vivo porcine model in the setting of colonoscopy. DESIGN Blinded quasi-experiment. SUBJECTS Six swine. INTERVENTION Colonoscopy with the swine under general anesthesia, with application of APC in 2 different pulsed modes and varying power settings and duration of application. MAIN OUTCOME MEASUREMENTS Surface area and depth of colonic mucosal injury. Qualitative histologic analysis of each site of APC application was performed on formalin-fixed specimens after euthanizing the swine. RESULTS Muscularis propria injury occurred in 22% of lesions with 10 W, 62% of lesions with 20 W, 86% of lesions with 40 W, and 80% of lesions with 60 W. Muscularis propria injury occurred in 42% of lesions at 1 second, 66% of lesions at 3 seconds, and 69% of lesions at 5 seconds. Depth of injury was significantly correlated with total energy delivered (P = .001, r = 0.75). Surface area was significantly associated with total energy delivered (P < .001, r = 0.81). LIMITATIONS This study was performed in distal swine colon rather than human colon. Colon tissue response to APC injury may differ from swine to human colon. The application distance from the APC probe to the colonic tissue may have varied between applications. CONCLUSIONS Muscularis propria injury occurs across a broad range of clinically used APC settings. The frequency of deep injury and the surface area of the lesion increases with total energy delivered. The lowest power settings (10-20 W) and the shortest durations have the lowest risk of deep tissue injury.
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Affiliation(s)
- Christopher J Goulet
- GI Division, University of Utah Health Sciences Center, 30 N 1900 E., Salt Lake City, UT 84132, USA
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Byrne KR, Panagiotakis PH, Hilden K, Thomas KL, Peterson KA, Fang JC. Retrospective analysis of esophageal food impaction: differences in etiology by age and gender. Dig Dis Sci 2007; 52:717-21. [PMID: 17253139 DOI: 10.1007/s10620-006-9499-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Accepted: 06/19/2006] [Indexed: 12/09/2022]
Abstract
Eosinophilic Esophagitis (EE) is an emerging cause of esophageal food impaction (EFI) not accounted for in previous studies. We sought to determine the causes of EFI in a recent cohort with recognition of EE. A retrospective chart review of all patients with EFI during the past 5 years was performed. Etiology was determined by endoscopy report, pathology results, and follow-up studies. A total of 85 EFIs occurred, in 79 patients (55 men, 30 women, age 18-100). The most common etiologies of EFI were Schatzki's ring (n = 18), peptic stricture (n = 18), EE (n = 9), esophagitis (n = 9), and no underlying diagnosis (n = 20). EE was significantly more frequent in men (P < .025) and those <50 years old (P < .025). There was a significant difference in the age at which men (median age = 44) and women (median age = 71) present with EFI (P < .001). The etiology of EFI differs significantly by age and gender. This information may be useful in evaluation and management of EFI.
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Affiliation(s)
- Kathryn R Byrne
- University of Utah Health Sciences Center, Division of Gastroenterology, 30 North 1900 East, SOM 4R 118, Salt Lake City, UT 84132, USA.
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Guo HF, Fang JC, Wang JP, Zhong WF, Liu BS. Interaction of Xestia c-nigrum granulovirus with peritrophic matrix and Spodoptera litura nucleopolyhedrovirus in Spodoptera litura. J Econ Entomol 2007; 100:20-5. [PMID: 17370804 DOI: 10.1603/0022-0493(2007)100[20:ioxcgw]2.0.co;2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Xestia c-nigrum granulovirus (XcGV) was tested for its ability to increase Spodoptera litura nucleopolyhedrovirus (SINPV) infection in larvae of S. litura (F.). The interaction of XcGV with peritrophic matrix and SINPV in S. litura also was studied to account for the synergism. In dose-response bioassays with a constant XcGV concentration of 5-mg/ ml capsules and SINPV concentration that varied from 10(3) to 10(7) polyhedral inclusion bodies (PIB) per larva, XcGV increased the virulence of SINPV infection in fifth instars of S. litura. The lethal concentration of 50% individuals (LC50) of SINPV combined with XcGV was 3.35 x 10(5)PIB/ml, which was significantly lower than that of SINPV alone (2.17 x 10(6)). Compared with 10(7) PIB/ml SINPV alone, the lethal time of 50% individuals (LT50) of 10(7) PIB/ml SINPV combined with XcGV was not significantly shortened. In addition, no significant improvement in the activity and killing speed of SINPV progeny was noted after propagation with XcGV, indicating that native characters of SINPV associated with viral potency were not altered by XcGV. Investigation via environmental scanning electronic microscopy showed that the peritrophic matrix (PM) of S. litura exposed to XcGV or XcGV enhancin, or the combination treatment, was markedly disrupted. The outer surface of the PM was loose, or ruptured, which potentially facilitated the passage of virions through the PM. Therefore, it is reasonable to conclude that the synergy between XcGV and SINPV was closely associated with the disruption of the PM in S. litura.
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Affiliation(s)
- H F Guo
- Institute of Plant Protection, Jiangsu Academy of Agricultural Sciences, No. 50, Zhongling Street, Nanjing 210014, China
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